OpenNotes at Beth Israel Deaconess Medical Center


Beth Israel Deaconess Medical Center (BIDMC) in Boston, MA, is an academic medical center affiliated with Harvard Medical School. It employs approximately 2,400 clinical staff, including 800 physicians and 1,200 registered nurses. BIDMC has649 inpatient beds and offers both hospital- and community-based ambulatory care. BIDMC developed its EMR beginning in the 1980s and opened its patient portal, PatientSite, in 1999. Approximately 65,000 patients have PatientSite accounts.

BIDMC first opened notes to patients of 39 volunteering primary care physicians in 2010, as part of the initial OpenNotes demonstration project. On review of the study’s results, the hospital’s Clinical Operations Executive Committee voted to open all clinicians’ notes, with a goal of implementation across ambulatory practices in 2013 and inpatient settings in 2014. The following summarizes the outpatient rollout.

Key features

  • Only notes signed after the OpenNotes start date are available to patients on the portal.
  • Clinicians may write a “monitored” note that is blinded to the patient online.
  • Clinicians can opt out with permission of their department chiefs.

Who is sharing notes?

  • Phased rollout began in the summer of 2013 with primary care, orthopedic, and rehabilitation services. Medical subspecialties began sharing notes with patients in the fall of 2013, and surgery and surgical subspecialties joined in Dec 2013
  • Nearly all outpatient clinicians who sign notes in the EMR – including attending physicians, house staff and fellows, nurse practitioners, physician assistants, physical and occupational therapists, nurses, and clinical pharmacologists — are sharing visit notes with patients. As of December 31, 2013, one physician in Medicine and five in Neurology had opted out
  • All medical residents and fellows participate in open notes. Medical student notes are not included.
  • A limited group of psychiatrists, social workers, and ObGyn doctors are participating in pilots before deciding how to adopt open notes throughout their departments.

How are notes being shared?

  • Patient’s access notes via a secure online patient portal called PatientSite.
  • PatientSite currently does not not have a “proxy” account access for specific populations.
  • After each appointment or visit, patients receive a secure message inviting them to read their visit notes; the clinician’s electronic signature triggers the message.

How did BIDMC introduce open notes to patients and clinicians?

  • Presentations by clinical champions at department meetings to educate staff on BIDMC’s OpenNotes initiatives.
  • Short video interviews with clinical champions and senior executives, including the CEO, posted on the employee portal.
  • Clinician OpenNotes FAQs posted on employee portal and department chiefs also e-mailed the FAQs to clinicians.
  • Announcement on patient portal homepage to notify patients of OpenNotes policies.
  • Patient FAQs posted on patient portal and sent to patients via PatientSite secure messaging.

Lessons learned from implementation:

  • Engaging leadership from the start makes a difference; having the support of the CEO, the Chiefs of Medicine and Surgery, and executive-level sponsorship were critical.
  • Don’t underestimate the importance of institutional culture. Clinicians need to be heard and their concerns respected; meet regularly with clinicians, be accessible to them when they have questions, and incorporate their ideas on open notes implementation.
  • Developing a communication strategy early helps clinicians prepare for what’s coming.
  • Rolling open notes out in stages allows room to make improvements or fix technical glitches that could turn off skeptical clinicians at the outset.
  • In teaching settings, open notes may pose challenges for trainee notes requiring cosignature since both providers must participate in open notes for patients to view the progress note online. This needs to be addressed proactively with educational leaders.
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